Tag Archives: health insurance exchanges

With the release of their new HeartAssist5 heart pump, ReliantHeart is making real-time, personalized feedback possible for the millions of Americans suffering from heart failure. The new technology allows for real-time, remote monitoring of implantable devices, years of added life for patients, and flexibility to travel without a physician nearby. With a staggering projected 46% growth in heart failure by 2030, advances in heart failure innovation are on the forefront of changing medical treatment, policy, device research and physician reimbursements. Further, with heart failure and disease disproportionately affecting minorities in the US, advances in length and quality of life could be huge strides for medical equality.

Heart Failure In America

Approximately 7.5 million people in the United States currently suffer from heart failure, a figure that is increasing over time as more people survive heart attacks and various other heart conditions. According to the Heart Failure Society of America, an estimated 400,000 to 700,000 new cases of heart failure are diagnosed each year, with deaths averaging 250,000 annually, more than double since 1979. Even worse, an estimated one half of heart failure patients die within five years of diagnosis and 20% within the first year.

With a waiting list for heart transplants at an overwhelming 3,736 at publication, and less than 2,500 hearts donated annually, the need for a bridge between heart failure and transplant is literally life and death.

LVADs

Left ventricular assist devices (LVAD) are implantable heart pumps that were created to temporarily support patients with advanced heart failure as the bridge between diagnoses and transplant. However, with new scientific advancements, LVADs are becoming a long-term tool for improving heart function without transplant.

The right ventricle pumps blood to the lungs, but the left ventricle is responsible for pumping blood to the rest of the entire body, making it much more susceptible to failure. Therefore, LVADs have been the focus of most modern research to prolong and improve life saving implants.

Patient-Centered Care

Reliant’s system acts like your car’s dashboard. “If a patient’s pump has any sign of a challenge, like dehydration or low flow, the remote monitoring system signals the change to a data-collection center that notifies the transplant center as well as the individual,” ReliantHeart CEO Rodger Ford says. This is what makes the HeartAssist5 unique; at the first sign of a problem the right people are notified immediately.

Essentially, if the engine light goes on, the heart center and patient are notified to get the engine checked.

He also notes that the patients can set monitors to send text message notifications, thus making changes in blood flow, speed and power truly personalized. Individual blood flow is collected and transmitted every 5 minutes, making one’s own body the standard comparator.

The greatest importance to Founder and CTO Bryan Lynch is his ability to use his background as an engineer to, “Get involved in a project where you can actually see how you saved a life. While the docs and nurses are the real lifesavers, we give them the tool to make it possible.” He continues that it is vitally important for engineers and innovators to gain a patient-centered approach to get a real reduction in cost burden and improve quality of life.

Sailesh Saxena, CFO, continues highlighting the patient focus of the company by telling about the origination of the design of the VAD pack. “Bryan and I used to go to Schlotsky’s Deli ($BUNZ) for lunch,” he said, “and we used to see this man wearing a coat although it wasn’t cold out. Bryan noticed immediately that he was attempting to hide an LVAD controller and batteries. Well, this happened more than once, and we recognized that he was always concealing the VAD controller. So we decided that we needed to create a unique insert so that our LVAD control system could slip right into a Louis Vuitton ($LVMH) or Gucci ($GUC) bag unnoticed. It’s the small things that make the patient feel like we understand what they really want.”

Expanding The Geography Of Care

Remote monitoring, like other methods of telemedicine, is a key to expanding the geography of health care. “As technology matures, with the help of remote monitoring, the cardiologist and patient will feel safer with greater distances between them,” says Saxena.

This growth in telemedicine as a whole, and specifically in heart care, has major implications for the Centers for Medicare & Medicaid Services (CMS) as well as health care policy and reform. Because CMS is beginning to assign reimbursements and penalties based on patient outcomes instead of traditional fee-for-service metrics, it will become more and more important to have reimbursements reflect remote monitoring and its likely benefits.

Reimbursement codes also need to be reworked to genuinely target geographic discrepancies in care, which are fundamentally important for transplant centers. However, at present, CMS is slowly beginning to take growth rates of heart implants seriously based on the agency’s continued increases in payments, including their slight variations in geographic differences.

An Engineering Feat

In a recent study, researchers found that platelets flowing through the HeartAssist5 are exposed to significantly lower cumulative shear stress levels than in competitive devices tested. Ultimately, this means that the ReliantHeart product allows for what the CTO calls “a more physiologically normal cardiac output, including the pulse.”

What Bryan means is that people with failing hearts have low blood flow throughout the body, which is why they are so sick. When an LVAD is implanted, patients return to a more normal flow, but they also need blood flow that is as natural as possible. With the HeartAssist5, blood is not damaged and any pulse that the recovering heart produces is naturally transmitted to the body.

The LVAD and heart now work together to help the patient recover.

Although there are two other continuous flow LVADs on the market (THOR and HTRW), the ReliantHeart team claims their careful design capitalizes on working with the natural ventricle to the benefit of the patient, almost like a gym trainer for your heart.

Their “implantable flow probe” is also a revolutionary aspect of the HeartAssist5. This ultrasonic probe measures the blood flow from the LVAD in real-time providing critical feedback that is a one-of-a-kind technology providing data that makes the aforementioned remote monitoring so valuable. Ford says this ability to see patient-specific trends remotely in real time not only helps all patients improve quality of life, but the longevity of the HeartAssist5 creates a life support system, far beyond the “bridge” that the LVAD was originally created to be.

So this month, for American Heart Month, think about what innovation really is. It might be the ability to prolong and add quality of life for individuals and families across the nation, to share more time with loved ones.

In five weeks from now, the Patient Protection and Affordable Care Act (ACA) mandates the opening of health insurance exchanges around the country. At that time New Yorkers will be introduced to an innovative way of thinking about health care: Oscar. Three friends, and technology entrepreneurs, teamed up to do something that has been inconceivable to date—create a start-up health insurance company to take on conventional health insurers on the NY exchange. Oscar co-founders, Josh Kushner, Kevin Nazemi and Mario Schlosser, plan to change the health insurance industry through technological interfaces, telemedicine and real transparency. Their goal is to redesign insurance to be geared toward the user experience, to make patients seek out their insurer before their doctor.

Americans do not usually think of health insurance as an intimate part of the care process. When sick, individuals do not call their insurance company for care or support. The health insurance industry is considered confusing, at best. The ACA however, presents an opportunity for the reformation of health insurance as we know it, not because of its disappearance, but by making it an integral part of receiving quality care. According to one co-founder, “We want consumers to feel like they have a doctor in the family.” That family doctor he speaks of is Oscar.

Oscar will have one plan in each of the ACAs metal-tiered categories, and additional plan options for the Bronze and Silver tiers. Although Oscar will have some of the familiar pillars of the health care industry like co-pays and deductibles for in-person visits, it introduces new elements like free telemedicine, free generic drugs and online price comparisons. Oscar health insurance will pioneer “a consumer experience, not a processor of claims,” explained Nazemi, with the goal of simply guiding individuals through the complex health system in an integrative and safe way.

Customer Service: What Oscar Can Do For You

Through user experience, customer service and innovative care options, Oscar will attempt to expand the role of the health insurance company to a health services provider. Oscar is being developed not just to cover medical costs, but to be the primary place to get the medical assistance a patient needs at any time.

When Oscar opens on the New York insurance exchange on October 1st, there will be a focus on function, ease of use and design. When a patient logs into HiOscar.com, he or she will want to keep using it like a new iPhone or laptop, or so the creators hope.

For frequent conditions or issues, patients will be able to find treatments right on the website and have 24/7 access to a physician through their unique partnership with the telemedicine company, TeleDoc. Additionally, the creators claim there will be no need to discuss prescription refills in-person with an expensive physician when a user can have “one-click refills” through a health records feed that resembles a Twitter timeline.

Oscar will also offer services at many hospitals and retail locations such as New York CVS CareMark. The partnership that Oscar and CVS have is so strong that CVS is building sites for Oscar. These added locations will serve as one method of addressing the physician deserts that exist in the state. The company also contends that Value Options is a strategic partner with the goal of making mental and behavioral health care more accessible for the newly insured.

Not everything will be brand new though. Oscar will offer several types of plans like traditional insurance companies, but the approach is slightly different. As Schlosser explains, “packages will be bundled like AT&T, which consumers are now accustomed to.” The intention is to eliminate many of the arcane rules of the insurance industry, which often frustrate patients and erode the customer service experience.

Schlosser tells a story of him, his wife and baby going to CVS in the fall of 2012 to get flu shots in New York City. Schlosser gets his shot, but when his wife goes for hers, she is rejected. The pharmacist explains that Mario’s insurance only covered one shot per 24 hours. Schlosser, who at the time was already working with Kushner and Nazemi on Oscar, explained that Oscar is designed specifically not to have such “Byzantine rules.”

Telemedicine: The Doctor Will See You Now

When describing key functions of their new company, Nazemi and Schlosser emphasize that telemedicine will be the method by which many of their objectives are accomplished. Although telemedicine has been around for a while, it has not been wildly popular with patients to date. Oscar hopes to change that feeling with new incentives, 24-hour online services and a sleek design.

The founders of Oscar claim that consumers will have access to a doctor by phone within 20 minutes of a request, with no co-pay. Perhaps the concept is not revolutionary, but if it works, the behavioral changes associated with seeking care could be seismic. Currently, not many patients log onto insurance carrier webpages before seeing a doctor, unless they are seeing if the doctor is in-network. Oscar, however, wants patients to start their care with the insurer, not just use it for payment submission.

Oscar also plans to have incentive programs such as the “10 for 10,” where patients will receive $10 for answering 10 questions about their health and preferences. The answers from those questions will then be used to establish proactive health care, as well as help the Oscar team make continual upgrades based on user preferences. For example, answers to the “10 for 10” might help create an outreach program for Diabetes patients where a registered nurse would come to the home, or the answers might inform web developers on how utilization could change in the future.

For added flexibility, Oscar asserts it will employ registered nurses and nurse practitioners to provide in-home follow-up services for patients if needed. In the case of new mothers, weekly visits to the home can be arranged if that is preferred over online interaction. Schlosser described his vision of this component as “integrating backwards,” where patients and providers interact in the settings they choose at the times they agree upon.

According to the creators, in addition to the partnership with TeleDoc, Oscar has already amassed some form of relationship with more than 83 hospitals in New York, hoping to make the telehealth to in-person relationship seamless.

Just How Transparent?

Transparency, the newest buzzword associated with the ACA, plays a dual role in the Oscar story. The availability of data drove Oscar’s operation and consumer focus, and has been an integral part of their ability to test their interface with government feedback. Schlosser describes tracking and analyzing years of medical claim data for entire episodes of care to help assess how technology and telemedicine may better treat patients. His go-to example relates to how many people use expensive physician time and technology for simple ailments like headaches, where large percentages of costs go to small percentages of patients.

Data analysis like Schlosser describes are only the beginning. As more medical data becomes available under the ACA, more and more relevant analyses will be conducted. The Oscar team is counting on this improved data to help them meet patient needs on the platform as well as potentially predict future health demands. Like their past Instagram endeavor, the group hopes to make data the backbone of sharing information.

Oscar’s creators were quick to stress that design and functionality are also deeply rooted in transparency. Schlosser explains that the interface will allow consumers to see price differences based on location, facility and desired services.

On Oscar, a user will supposedly be able to look up prices for doctors across the street from one another or shop for MRI pricing by facility. Schlosser boasts that patients will be able to view “heat maps of services and providers.” The question, however, of whether patients will actually log on to compare prices remains unanswered. Human behavior indicates that unless cost savings are passed on to the consumer, there is very little incentive to look for or care about alternatives.

Media Experts As Marketers

Oscar’s founders plan to target all uninsured in their market area. Based on Oscar’s innovative approach to insurance, and the creator’s unique backgrounds in social media, the marketing endeavor will surely be novel. Nazemi says that the approach to courting the uninsured will “include traditional and nontraditional forms of media,” with the ultimate goal being, “to win over every consumer.” This winning of the consumer, or patient, will include all of the feedback mechanisms and personal interaction that allow for real time updates to the company.

Although Oscar will be targeting the entire uninsured population in their New York market, it is likely that the young, healthy and social media savvy will be the easiest to penetrate with marketing materials. This population, however, has been of the greatest concern for the constructors of the ACA, and the reason the individual mandate exists. As time progresses we will see how Oscar uses its flexibility to attract and maintain a young and healthy population that is the least likely to pay for insurance.

Currently, the Oscar site is merely a welcome page and a list of open positions within the company. But, on October 1st, the site will be fully functioning, possibly putting other sites and insurers to shame. It is certain, given its creative employee background, that the feel and design of Oscar will be more user friendly than the state-based or federal sites.

According to Schlosser, the idea for consumer usage is to have a site where, “like Google, you can come use Oscar. You can type in your issue and we will help you find the best solution.” He explained that the entire experience will be interactive.

When asked about their role or faith in the success of the ACA, the team commented that, “the ACA is a catalyst for what we’re doing.” And the creators hope that Oscar will become a catalyst for the rest of the health insurance industry to be more transparent. They claim Oscar will set the stage for new expectations and behaviors by consumers, and that people already know they deserve more from their health care system.

Whatever the success of Oscar in the early stages of the exchange market in New York, one thing is for certain; Oscar has the potential to cause much needed disruption to health insurance and health care.

Beginning in 2013, states will begin rolling out health care insurance exchanges as required by the Affordable Care Act (ACA). To this point most legislators, policymakers and health care experts have discussed the state-based and federal insurance exchange options at length. However, there is another form of insurance exchange that states are beginning to explore: the “partnership”.

In a state-federal partnership, states will divide obligations with the federal government. For this partnership model there is no requirement for a 50-50 split of labor, and the states are actually more of a facade whereby the consumers (individuals and employers) merely interact with the state. The federal government, on the other hand, will essentially perform all functions of the exchange management except customer service and plan management. Moreover, states have the choice to run either one or both of those functions. According to former head of insurance exchange planning at HHS Joel Ario, “States that choose this option are ceding the more technical aspects of exchange activity to the federal government but can retain control of insurer oversight and consumer assistance.”

In the state-federal partnership model, the federal government will operate everything from consumer eligibility and enrollment to financial management and risk corridors. This essentially means that the federal government will take on most responsibility for the exchange, while granting states many of the perks they would receive if they had created a state-based exchange.

If the federal government is left to the heavy lifting, what exactly will the states portion of labor entail? The states can choose to be responsible for plan management, meaning they will be charge of qualified health insurance plan certification and reinsurance, data collection and basic supervision. The states can further choose to be in control of customer service functions such as in-person assistance. Nonetheless, even in this case, the federal government will oversee the websites and call centers where the heavy lifting will occur.

To date, only a few states have revealed that they intend to participate in a state-federal exchange. Illinois, whose Governor Pat Quinn announced its intention to run a partnership exchange in July of 2012, has already received $39 million for the state, and this sum does not even include Medicaid expansion. Arkansas has been making significant progress on their partnership since 2011. For its hard work, the federal government has given the state nearly $9 million in grants.

For more detail about the current responsibilities of the partnership, visit the PwC “Anatomy of an Exchange” chart created with data from the Robert Wood Johnson Foundation.

Nicole Fisher’s first Wright on Health post earlier this week has generated a substantial amount of buzz, being picked up by both The Health Care Blog and Health Works Collective. It also generated a couple of comments, which is encouraging, and one of those was worth sharing again in its own post.

This post is written by new Wright on Health blogging partner Nicole Fisher. Nicole is the Senior Policy Director at Health Systems Innovation Network where she does health economic and policy analyses generally focusing on Medicare, Medicaid and health reform. She also is a current PhD student at the University of North Carolina in the Health Policy and Management Department and writes on a variety of health care topics for several think tanks and websites. Nicole also has a masters degree in Public Policy from the University of Chicago and an undergraduate degree from the University of Missouri.
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With less than two years before state-based health insurance exchanges are to be operational, most state legislators and health policy experts still cannot come to an agreement on how to set up, operate, monitor or fund state exchanges. However, despite persistent confusion and concerns surrounding health insurance exchanges, the White House recently released a report on the progress of state-level health insurance exchanges. This publication took a favorable and possibly misleading view of the headway being made by states that are creating their online insurance marketplaces.

The Administration claimed that there are currently 28 states making great progress in establishing an exchange. Even if that were true, this indicates that 22 states -or about 40 percent- are refusing to comply with the Patient Protection and Affordable Care Act (PPACA).

Although the report does not lie, it also doesn’t exactly accurately portray where most states stand either… The Administration chose to furtively count states that fall into a grey area as making progress toward setting up an exchange. Many states have, in actuality, refrained from any legislative activity or the state legislature has merely set up a committee to “study options”. What this really indicates is that many states are purposefully not complying with the PPACA mandate to create an exchange, but also managing not to violate it so that they are allowed to keep federal funding, at least until the January 2014 deadline.

Figure 1 below illustrates exchange status more accurately by categorizing, into six categories, where states stand in terms of state-based exchange implementation. These classifications range from states that have already established an exchange to states who have taken legislative action not to create an exchange.

As the White House rightly exhibited, there are a few states that have made significant progress in setting up an exchange and benefited greatly from the extra federal dollars. Rhode Island recently received an additional $60 million from the federal government for their collaboration with Massachusetts and Vermont to improve system integration associated with health insurance exchanges. California, Colorado and Washington have also seen legislation signed into law following the passage of PPACA to implement a state health insurance exchange.

In contrast, based on a February 2012 analysis of all states, Figure 1 shows that five states have no legislative activity whatsoever related to a health care exchange; and several states such as Wisconsin, Louisiana and Florida not only rejected setting up an exchange, but returned the grant money bestowed to them from the federal government to establish an exchange. More common scenarios, and where Figure 1 differs from the White House, are that many states are merely “investigating options” or allowing an exchange bill to bounce around legislative committees but never go to a vote. These alternatives allow states to keep their federal funding, but take no action to set up an exchange.

For example, the state of North Carolina had a Republican majority who drafted an exchange bill. That bill, however, was moved from one committee to another over than span of months for “reading.” For the past year, that same bill hasn’t seen the light of day and the Republican majority has no intention of ever letting it. This way, the state is allowed to spend federal exchange dollars, but not actually carry out the Administration’s plans. New Hampshire also had an exchange bill written, but after passing the Senate, that bill failed to pass the House of Representatives. In doing so, New Hampshire was allowed to keep exchange funding, but use the stalemate as a way of not having to revisit the idea of exchange implementation until a future session. South Carolina on the other hand used the original Exchange Planning Grant from the federal government to create an exploratory committee on exchanges, but decided after its creation that no legislation should be written.

As the economic crisis continues, unemployment remains high and the Supreme Court prepares to hear oral arguments for various provisions of PPACA in March, the number of states moving forward with enacting an exchange should become stagnant. This could further undermine the “progress” being made by states that fall into the grey area. Regardless, whether states are stalling efforts to create state-level exchanges, “studying” alternative options and costs, or flat out rejecting the idea, it’s safe to say that the optimism demonstrated in the White House report is a bit rosier than the real state of state-level health insurance exchanges.